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Executive Summary

Ethics consults often are called only after the patient lacks decision-making capacity and death is inevitable despite aggressive treatment. To encourage earlier consults, ethicists can do the following:

routinely offer brief education to physician and nursing staff,

participate in various hospital and medical staff committees, and

encourage questions about cases during ethics rounds.

By far, the most common situation in which ethicists are asked to provide consultation is when conflict occurs near the end of life, according to David A. Fleming, MD, MA, MACP, director of University of Missouri’s Center for Health Ethics in Columbia.

Unfortunately, this often occurs when death is inevitable in spite of aggressive treatment. “Both team members and family are distraught, and the patient is no longer capable of engaging,” says Fleming. “Disagreements and emotions run high at these times.”

Earlier involvement of the ethics team can facilitate discussion at a time when the patient can engage in shared decision-making, along with the family and the team. “Then clear statements of value, preferences, and beliefs can be expressed, heard and understood by everyone,” says Fleming.

Clinicians lack awareness

In Fleming’s experience, there are two major reasons clinicians fail to utilize ethics consult services when needed. “Either they don’t recognize that ethical conflict exists, or they find it too cumbersome or uncomfortable to call for a consult,” he says. This may be due to time constraints or fear of judgment about the case.

In some cases, physicians and nurses either don’t know ethics consult services are available or don’t know how to engage them. Here, clinical ethicists offer the following recommendations to promote utilization of ethics consults:

• Become a frequent presence in the care arena. “Being open to questions about cases is a stimulus to begin discussions,” says Fleming. By conducting “ethics rounds” on a regular basis, ethicists are in close proximity to care teams in the hospital, making themselves directly available when and where decisions need to be made.

“Case conferences are a good way to bring multiple disciplines together in the discussion,” suggests Fleming. For instance, the team may question whether treatment decisions are in the patient’s best interest. “This suggests that conflict is either in play now, or soon will be,” says Fleming.

Fleming says it can be helpful, upon hearing such concerns, to informally offer suggestions as to ethical responses that might be considered. “But it is also important to offer the opportunity to formally meet with all stakeholders — care teams, consultants, patient, and family — to fully flush out the issues and make decisions in a shared way,” he says.

Steven S. Ivy, MDiv, PhD, senior vice president of values, ethics, social responsibility, and pastoral services at Indiana University Health in Indianapolis, says bioethicists should seek opportunities to offer even brief continuing education to physician and nursing staff. “Be available on a regular basis during rounding for ‘on the fly’ conversations,” he advises.

• Get the word out by offering contact information on websites and other key communication venues. University of Missouri’s website lists a phone number and email address for the Center for Health Ethics, where the ethics consult service is coordinated and run, as well as the pager number for the consultant on call.

• Provide educational sessions and case discussions. “This fosters awareness, and a willingness to call for assistance when difficult cases arise,” says Fleming. When the consult team gets one ethics consult, several requests often follow from the same service.

“When care teams see how we have facilitated discussion and mediation in often complex cases and helped to provide resolution to conflict, they see value in our presence,” Fleming says.

• Do not reinforce perceptions of the “ethics police.” Sometimes physicians and nurses call ethics seeking to enforce a desired behavior pattern on others. In such cases, advises Ivy, “the ethicist needs to probe enough to hear what ethical challenges may be present, and if they are, transform the conversation to those issues rather than a violation of mores or standards.”

At Indiana University Health, risk management or professional standards would intervene in the case of policy violations; professional standards would intervene in inappropriate behavioral situations. “If clinicians accuse colleagues of violating hospital policy, there are other mechanisms for those issues, when they are actually present,” explains Ivy.

• Be pragmatic in recommendations. “While the ethicist must have deep knowledge of theory and history and must use that knowledge effectively, not too often are clinicians attuned to hear such discourse,” says Ivy. Consultations about appropriate courses of action must be useful in the actual course of patient care.

“Usually the clinician will not find interesting or helpful a discourse on levels of autonomy and capacity to refuse recommended treatments,” Ivy says. In his experience, clinicians appreciate clear statements as to the ethicists’ evaluation of the particular patient’s capacity for accepting and refusing treatments.

• Participate in various hospital and medical staff committees. This “is not often exciting, but can pay great benefits in being known and appreciated,” says Ivy. “Face knowledge is really important.”